PEDIATRIC FORMS PRINTABLE PDF PATIENT’S NAME First Last DATE OF BIRTH Date Format: MM slash DD slash YYYY If this form is completed by a parent/guardian, what is your relationship to the child?PRESENT SITUATION: In what ways do you seem to have difficulty? (How does your child complain about his or her vision?)Has anyone noticed an eye turn in or wander out?YesNoWhich eye?When?Do you experience any of the following. If yes, when? Headaches Blurred Vision Far Blurred at Near Eyes Hurt or Tired Double Vision Light Sensitivity Have you ever noticed the following? Holding reading close Holding reading farther away Distorted posture when reading Inability to see distance objects Closing one eye Covering one eye Bumping into objects Poor general coordination Eyes frequently reddened Frequent styes Excessive eye rubbing Skips words or rereads Reverses words/letters Moves lips while reading quietly Get lost in book/unaware of surroundings Moves head while reading Uses finger to follow words Tilts head while reading Bothered by light Does the patient have a speech or language deficit?YesNoIf Yes, has any attempt been made to correct it?YesNoBy Whom?Was therapy helpful?YesNoHave you ever had any eye surgeries or injuries?YesNoPlease ExplainHave you ever had vision therapy?YesNoWhen?By Whom?Was it helpful?YesNoDoes your job/school include using a computer tablet? hours/dayHow do you spend your free time?How many hours a day do youuse a digital devicereadwatch TVAre you involved in sports?YesNoWhich one(s)What kind of exercise do you do?